{template 'common/header'}
<link id="barindexCss" rel="stylesheet" href="../addons/meepo_bbs/template/mobile/default/style/base.css" />
<link id="barindexCss" rel="stylesheet" href="../addons/meepo_bbs/template/mobile/default/style/style.css" />
<script type="text/javascript" src="../addons/meepo_bbs/template/mobile/default/style/script.js"></script>
<title>兑奖信息</title>
	<section class="reserve">
    	<!--content-->
        <section class="reserve_content">
        	<!--title-->
            <p class="reserve_title"><span>请认真填写收件人信息,客服人员将会与您联系</span></p>
            <!--tielt end-->
            <!--details-->
            <section class="reserve_details">
			{php foreach(explode("-",$goods_info['title']) as $v) echo "<p>" . $v . "</p>"; }
            </section>
            <!--details end-->
			<!--data-->
			<section class="reserve_data">

			<form action="" method="post" data-ajax="false" onsubmit="return check(this)">
				<input name="id" type="hidden" id="id" value="{$goods_info['id']}" />
				<input name="request_id" type="hidden" id="request_id" value="{$request_id}" />
				<input name="a" type="hidden"  value="entry">
				<input name="m" type="hidden"   value="meepo_bbs">
				<input name="do" type="hidden"  value="home_credit_exchange">
				<input name="uniacid" type="hidden"  value="{$_W['uniacid']}">

				<section class="data_box">
				<label class="data_box_l">真实姓名</label>
				<span class="data_box_r"><input type="text" name="realname" value="{$profile['realname']}" placeholder="请输入您的真实姓名" class="txt" /></span>
				</section>
                <section class="data_box">
                    	<label class="data_box_l">联系电话</label>
						<span class="data_box_r"><input name="mobile" type="text" value="{$profile['mobile']}" placeholder="请输入您的手机" class="txt" /></span>
				</section>
                 <section class="data_box">
                    	<label class="data_box_l">邮寄地址</label>
						<span class="data_box_r"><input name="residedist" type="text" value="{$profile['residedist']}" placeholder="请输入您的邮寄地址" class="txt" /></span>
				</section>
                  <section class="data_box">
                    	<label class="data_box_l">备注</label>
						<span class="data_box_r"><input name="note" type="text" value="" placeholder="若非寄本人,注明客服可联系电话" class="txt" /></span>
				</section>
             
                    <!--btn-->
                    <section class="reserve_btn_box">
                        <input type="submit" value="提交登记" class="reserve_btn" />
                    </section>
                    <!--btn end-->
					<input type="hidden" name="token" value="{$_W['token']}" />
                </form>
            </section>
            <!--data end-->
        </section>
        <!--content end-->
		</section>

		<!--p><a href="{php echo create_url('mobile/module/goods', array('name'=>'quickcredit', 'weid'=>$_W['weid']))}">跳到兑换页面</a></p-->
		<script type="text/javascript">
			function check(form) {
				if (!form['realname'].value) {
					alert('请输入您的真实姓名！');
					return false;
				}
				if (!form['mobile'].value) {
					alert('请输入您的手机号码！');
					return false;
				}
				if (!/^1[0-9]{10}/.test(form['mobile'].value)) {
					alert('请输入正确的手机号码！');
					return false;
				}
				if (!form['residedist'].value) {
					alert('请输入您的邮寄地址！');
					return false;
				}
				return true;
			}
		</script>

		{template 'common/footer'}
